Psychosomatics 41:301-310, August 2000
© 2000 The Academy of Psychosomatic Medicine
Constant Observation Practices in the General Hospital Setting
A National Survey
Linda L.M. Worley, M.D., FAPM,
Elisabeth J.S. Kunkel, M.D., FAPM,
David F. Gitlin, M.D., FAPM,
Lynette A. Menefee, Ph.D., and
Gregory Conway
Received August 11, 1999; revised December 20, 1999; accepted January 12, 2000. From the Department of Psychiatry, University of Arkansas for Medical Sciences; the Department of Psychiatry and Human Behavior, Thomas Jefferson University; and the Department of Psychiatry, University of Massachusetts Medical Center. Address reprint requests to Dr. Worley, UAMS, Department of Psychiatry, 4301 W. Markham, Slot 789, Little Rock, AR 72205; email: WorleyLindaL{at}exchange.uams.edu
|
ABSTRACT
|
The authors conducted a national survey of 355 general medical/surgical hospitals to assess constant observation (CO) practices. The authors assessed overall use, expense, staffing patterns, funding strategies, and cost-saving interventions. Virtually all responding hospitals (N=102) reported using some form of CO. Several hospitals reported significant decreases in CO expenditures after the implementation of cost-saving interventions (the largest annual decrease reported was $340,000). Cost-saving interventions included utilizing consolidated bed spaces, relocating patients near nursing stations, placing at-risk patients in bed enclosure devices, and regularly assisting patients to the toilet. In addition, less costly personnel were hired, and volunteers and/or patient family members provided CO (or were required to assist with the cost of CO). Finally, hospital staff were educated about the costs and the appropriate use of CO. They were also taught to recognize and effectively treat delirium.
Key Words: Constant Observation
|
INTRODUCTION
|
Frequently, general hospitals must face the burden of caring for patients with acute medical or surgical illnesses who are also at risk of harming themselves or others. These patients may manifest a wide range of difficulties, including confusion, impulsivity, problematic behaviors, and substance intoxication/withdrawal.1,2 Perhaps the most frightening concern is the potential for suicide. Several authors have described the risk for suicide in general hospital settings.3–7 In an effort to ensure the safety of these at-risk patients, hospitals frequently employ restrictive measures to secure and to monitor these patients. Some of these measures, such as seclusion, physical restraint, and chemical restraint, may be overly restrictive at times and have increasingly been seen as problematic. Hospital review organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have recently drafted extensive guidelines on the use of such measures and have proposed recommendations for continuous face-to-face observation by an assigned staff member for patients placed in seclusion or restraints.8 The efforts of JCAHO and other groups such as the National Alliance for the Mentally Ill (NAMI) to reduce the inappropriate use of seclusion and restraint in general hospitals has spurred the search for alternative approaches. One increasingly common approach is to assign an individual to "sit with" or to maintain a one-to-one "constant observation" (CO) rather than implementing restrictive measures. Other frequently used terms for CO include continuous observation,9,10 one-to-one observation,11 special observation,12 and maximum observation.13
Despite the universal challenge of caring for at-risk patients, a comprehensive review of the literature on the use of CO in general hospitals reveals primarily regional or program specific publications. In 1984, Goldberg14 administered a 28-item questionnaire assessing the use, cost, and policies governing CO for potentially suicidal patients to 48 New England general hospitals, including urban, rural, university, and community hospitals. Of the responding hospitals, 92% reported using CO as a method to manage at-risk patients, at a significant annual cost.14 Goldberg studied the characteristics of patients placed on CO at his Rhode Island hospital in 1986 and found that they were suicidal, agitated, psychotic, confused, and/or unpredictable.2In 1996, Lamdan and colleagues found the most common indication for CO at their 350-bed urban teaching hospital was confusion and suicidality, with the duration of CO ranging from a few hours to 63 days.15 They also reported inconsistent documentation for the need, course, and termination of CO.15
The implementation of mandatory psychiatric consultation(s) to authorize CO has been shown to reduce CO expenditures by Goldberg,2 Lamdan et al.,16 and O'Dowd17 but requires an increased expenditure of professional consultation-liaison (C-L) psychiatry time. Lamdan et al.18 studied the use of CO in three urban sites (New York City, Philadelphia, and Syracuse) where they found that only 12%–14.5% of patients evaluated by the C-L psychiatrist required CO.
Data on the use of alternative approaches to CO is scarce. Although inpatient general psychiatry units occasionally have been used to help manage medically ill patients with prominent psychiatric disturbances, frequently these units are not equipped or staffed to manage acute medical illnesses. Medical-psychiatry units are more suited to handle serious medical problems but are often primarily psychiatric units that emphasize the provision of full psychiatric care rather than units emphasizing behavioral management within a primarily medical setting.19 Some data suggest that managing psychiatric patients in collected or "clustered" beds on medical wards20 offers significant advantages to the scattered-bed organization seen in most general hospitals. Finally, Santulli and Oxman21 report on the preliminary use of a bed enclosure device for agitated older patients at risk of falling.
It is assumed that CO is a costly practice, one that most institutions would prefer to reduce. C-L psychiatrists may feel this pressure and improperly respond by avoiding CO even when it is indicated. It is appropriate for C-L psychiatrists to collaborate in controlling the use of CO and continuing to provide quality clinical care for high-risk patients.
Whether regional CO practices can be extrapolated to understand national practices is unknown. This study attempts to elucidate the patterns of CO at the national level in hopes of learning effective funding strategies and innovative interventions designed to maintain the utmost safety of at-risk patients while containing CO costs. We tested the following five hypotheses:
- The majority of general hospitals use CO practices to manage at-risk patients;
- The use and cost associated with providing CO services in the general medical setting are often poorly monitored;
- The presence of an inpatient psychiatric unit and/or a substance abuse unit decreases the use and cost of CO;
- The presence of C-L psychiatry services decreases the use and cost of CO; and
- Requiring psychiatric consultation to authorize CO decreases overall CO use and cost.
|
METHODS
|
Selection of Hospitals
We selected general medical/surgical acute care hospitals (N=353) to be surveyed from the 1996–97 American Hospital Association (AHA) Guide to the Health Care Field.22 We sampled approximately 1 hospital per every 743,000 citizens throughout the United States and the District of Columbia. Representative hospitals were chosen based on their size and their available services. Whenever possible, hospitals with more than 200 beds were chosen. The largest hospitals in existence within the less populated states were chosen.
Of these selected hospitals,22 the four following distinct groups were identified based on the availability of various services thought to play potential role(s) in CO practices:
Group A=81 (23%) hospitals with no inpatient psychiatry services and no C-L psychiatry;
Group B=81 (23%) hospitals with inpatient psychiatry service but no C-L psychiatry;
Group C=81 (23%) hospitals with no inpatient psychiatry services but with C-L psychiatry; and
Group D=110 (31%) hospitals with inpatient psychiatry service and with C-L psychiatry.
We mailed the survey initially in March 1997. A second mailing to nonresponders was sent out in June 1997. Hospital administrators were telephoned after the second mailing and were educated about the purpose of the survey and were invited to participate. Additional telephone communication occurred in July 1999 between the primary author and 12 of the 13 sites reporting that they did not use CO to elicit innovative strategies to manage at-risk patients.
Survey
This survey (see Figure 1) was adapted from a pilot survey administered by D. Gitlin (unpublished), which was an expansion of Goldberg's14 previous work.
Data Analysis
We entered the data from questionnaires and analyzed the data using SPSS (statistical package for the social sciences). All data presented is descriptive in nature.
|
RESULTS
|
Characteristics of Hospitals
Of 353 surveys, 102 (29%) were returned, representing 37 of the 50 states and the District of Columbia. A geographically representative sample was obtained and included a diverse group of hospitals. The majority of the respondents (68%) were from nongovernment and nonprofit institutions. Other participants were from government (nonfederal) institutions (21%), for-profit institutions (3.1%), and federal government institutions (7.8%).
Ninety-four hospitals reported the number of medical/surgial beds ranging from 31 to 842 beds (mean±SD=361±196). Fifty-eight hospitals reported an annual number of admissions ranging from 346 to 43,219 (mean ±SD=15,751± 10,849). Sixty-four hospitals reported having medical/psychiatric beds with a range from 1 to 43 beds (mean±SD=16±12).
The 102 returned surveys were from the following groups:
Group A=15 hospitals with no inpatient psychiatry services and no C-L psychiatry (15/81=19% return rate from this group representing 14.7% of the total sample).
Group B=24 hospitals with inpatient psychiatry service but no C-L psychiatry (24/81=30% return rate from this group representing 23.5% of the total sample).
Group C=21 hospitals with no inpatient psychiatry services but with C-L psychiatry (21/81=26% return rate from this group representing 20.6% of the total sample).
Group D=42 hospitals with inpatient psychiatry services and with C-L psychiatry (42/110=38% return rate from this group representing 41.1% of the total sample).
CO Practices
By their responses, 87.3% of hospitals reported using CO (n=89) at their institutions in 1996. Follow-up telephone interviews with health care providers from 12 of the 13 institutions reporting no use of CO (12.7%) revealed that all 12 do resort to some form of one-to-one observation to manage high-risk patients.
Compared with the amount of CO the previous year, 14% of respondents reported that the frequency of CO at their institutions was decreasing. One-third (33.3%) reported that their use of CO was unchanged and more than half (52.6%) reported that their use of CO was increasing.
Fifty-nine hospitals responded to the question "What percentage of your total CO occurred on nonpsychiatric wards (in the general hospital)?" Twenty-five respondents "did not know;" 11 reported that 100% of their CO occurred in the general medical hospital; and the remaining 23 respondents reported a range from 1%–99% of their total CO occurring in the general medical hospital (average=64.8%).
Availability of C-L Psychiatrist
Of the respondents, 82% described having C-L psychiatry staff available in their hospital. Thirty percent (30%) of respondents reported supplementing their C-L staff salaries from their hospital budget(s). Only a few hospitals (n=17) provided the number of funded full-time-equivalents (FTEs) for C-L staff, with the average being 1.14±0.69.
Requirements for C-L Psychiatry Consultation
Forty percent of hospitals responded that they required a psychiatric consultation for patients who required CO. Eighty-nine percent of hospitals reported requiring a psychiatric consultation for patients who had attempted suicide. A limited number of respondents (n=31) indicated the following percentages of patients on CO who received a psychiatric consultation: 5 reported that less than 5% of patients on CO received psychiatric consultations; 9 reported that 15%–50% of patients on CO received psychiatric consultations; and 17 reported that 70%–100% of patients on CO received psychiatric consultations.
CO Provider Qualifications
Hospitals used a variety of professionals to provide CO. Providers included registered nurses (RNs) (52%), licensed practical nurses (LPNs) (43%), nursing assistants (75%), medical students (1%), family members (29%), and nonclinical hospital employees (16%). Other providers (33%) were sitters, chaplains, psychiatric technicians, student nurses, volunteers, and secretaries. Many hospitals used multiple types of CO providers.
CO Standards and Provider Training
Seventy-five percent of respondents described having a written policy for CO. Only 58% of respondents required CO provider training. These training programs were led by staff nurses, psychiatric nurses, emergency room personnel, psychiatry staff, or by the outside agency employing the CO provider. Training requirements ranged from no training to on-going training, including competency assessments. New employee orientation was reported to be a convenient time to provide training for potential CO providers.
CO Authorization Privileges
All respondents indicated that any physician could authorize CO. A nurse (RN, LPN, or nurse specialist) could authorize CO in 29.4% of hospitals, although many hospitals required that a confirmatory order be obtained from a physician. Sixteen percent of hospitals allowed others to authorize CO, including clinical supervisor(s) and administrative personnel. All respondents indicated that discontinuation of CO could be authorized by a medical doctor. Nurses (e.g., RNs, LPNs, or nurse specialists) could discontinue CO orders only in 11.8% of hospitals.
Indications for CO
Only 29 of our 102 respondents completed questions describing their institutional indications for CO. Suicidal ideation (96%), confusion or delirium (72%), homicidal ideation (48%), and elopement risk (48%) were the most common indicators for CO. Other respondents reported using CO for at-risk patients because of seizure disorders, ventilator dependency, and/or eating disorders. Occasionally, patients who were incarcerated or who were thought to be at risk of harm from others were placed on CO (e.g., abusive family members).
Documentation Requirements
A majority of respondents (n=94) answered questions about record-keeping requirements for CO. Hospitals required physician orders (81%), nursing records (95%), staff records (29%), and/or other records (15%). Various "other record-keeping requirements" included the following: a seclusion checklist, a CO flow sheet, CO initiation, and discontinuation records and CO chart notes (e.g., every half hour).
CO Expenses/Use
Of the 76 hospitals initially confirming their use of CO, 47 (61.8%) reported that they did not track CO-related expenditures or CO use rates. Twenty-nine hospitals (38.2%) reported annual CO expenses for 1996 ranging from $3,978 to $565,370 (see Figure 2).
Four additional hospitals reported their 1996 CO utilization in "hours" ranging from 1,152 to 24,890 hours.
Cost-Saving Interventions
A number of cost-saving interventions for CO were described by survey respondents (see Table 1). Twenty-two percent of hospitals reported consolidating bed space for patients on CO to decrease staffing costs (by providing 1:2 or 1:3 rather than 1:1). Others worked to reduce the need for CO through educational programs (e.g., reducing medication-related and other etiologies of delirium, appropriately using CO, and disseminating information regarding the costs of CO). Some hospitals focused their interventions on monitoring the ongoing need for CO, which requires frequent reassessment and/or "stop" policies after a specified period of time (e.g., 24 hours) unless the order is renewed. Blessing Hospital, in Quincy, Illinois, developed "SAFE: Staff Against Falls Everywhere," which is a comprehensive program consisting of daily assessment of each patient's risk beginning at the patient's admission. The hospital implemented safety measures for patients with three or more of the following risk factors: 1) age 75 or older; 2) permanent physical/neurological disability (e.g., blindness, amputation, paralysis, or sensory loss); 3) history of previous falls; 4) misuse of drug or alcohol prior to admission; 5) unsteady on feet (e.g., using assistive devices, weakness, or being a new amputee); 6) neurological problems (e.g., dizziness, vertigo, perceptual deficit, sensory loss, or visual changes); 7) behavior (e.g., uncooperative, belligerent, or overly independent); 8) level of awareness (e.g., confused or disoriented); 9) bowel preparations or diuretic use; and 10) sedative, hypnotic, or narcotic use. The SAFE protocol includes a patient and family educational component, bed alarm activation (as well as other interventions), and staff reminder warning labels (personal communication; Connie Schroeder, Sr. VP, RN).
Many hospitals reduce the cost of CO by employing less-costly CO providers. Respondents reported an increase in the use of family members, LPNs instead of RNs, volunteers, and patient observers. Several respondents required C-L psychiatric consultation for patients on CO and/or the transfer of patients requiring CO to an inpatient psychiatry unit or an intensive care area where they could receive closer observation by fewer CO providers. Some hospitals charge the families of patients requiring CO (when CO is used for purposes other than to prevent suicide). One respondent indicated a charge of $100 per shift for the provision of CO. Technological aids such as bed-enclosure devices were also used as an alternative to an in-person CO. One hospital reported investigating the use of cameras and intercoms for the remote monitoring of CO patients.
Funding Strategies
Respondents reported that funding for CO is most often provided by inclusion within the hospital's rate (n=50), but funding was also reported to come from hospital (n=7) or departmental funds (n=19), billing patients (n=11), and charging third-party payers (n=15). Respondents did not specify whether they actually received reimbursement from the insurers who were billed. Follow-up communication confirmed the lack of reimbursement from third-party payers.
|
DISCUSSION
|
Maintaining the safety of at-risk, patients (of harming self or others) within a general hospital setting is a dubious responsibility. Failure to do so places both the institution and its health care providers in a tenuous position, vulnerable to costly litigation.23,24 In a review of 32 cases of completed suicide, Peer23 reported several settlements in the range of $30,000 to $500,000. Fiesta24 reported a $3.6 million damage award for a patient who suffered brain injury because of an inadequate CO. Settlements are frequently related to inadequate documentation practices and/or the absence of a hospital policy with specific guidelines for managing suicidal patients.23
In this era of cost containment with decreasing reimbursements, hospital operating budgets are straining to support crucial programs and have limited means to fund nonreimbursable expenditures. Maintaining the safety of these at-risk patients is one of these costly, but essential nonreimbursable expenditures. The stakes involved in this particular balance between controlling costs and providing quality care may be quite high, including increased risks of suicide, serious falls, and potential elopement of patients who may be dangerous to themselves or to others. With the trend toward decreasing staff-to-patient ratios in order to balance decreasing hospital budgets, patients potentially at risk of harm have even less supervision. This national survey represents an effort to discover creative, cost-effective, and quality solutions for this universal problem.
CO is Practiced Nationwide
All general hospitals reported use of CO to manage at-risk patients (confirming our first hypothesis). The 13 hospitals (12.7%) who initially returned written surveys reporting no use of CO at their institutions in 1996 were recontacted in July 1999. An individual (at 12 of these institutions) knowledgeable about practice patterns for these at-risk patients was located and interviewed. All acknowledged using some form of CO and many had useful intervention programs in place (see Table 1). When queried regarding the original negative responses received from hospital administrators, most reported that their hospital administrators "probably just weren't aware of their day-to-day practices." (The discrepancies between the responses completed by hospital administrators and the verbal responses given by those involved on a day-to-day basis in the management of at-risk patients was a significant limitation of this study.) Only one site stated that they did not have CO in 1996 but they instituted it soon thereafter because of liability concerns.
Intervention Strategies
Many programs share elaborate means for minimizing CO (see Table 1). Significant decreases in CO expenditures were reported (the largest annual decrease reported was 75% representing $340,000 annually).
Using family members to provide CO for their relatives can be a valuable cost-saving measure, but it must be used judiciously. Family members are not trained professionals, and their personal relationship with the patient may cause them to underestimate risk, leading to inadequate observation. Occasionally, a family member exacerbates familial conflict, which can worsen the situation. Either of these circumstances may have disastrous consequences. Finally, family members may not be comfortable with this responsibility in the hospital and may find their employment in jeopardy if prolonged absences are necessary.
Absence of CO Standards of Practice
The lack of uniformity between respondents regarding their CO practices was remarkable, with one exception. Almost all hospitals empower physicians to initiate and discontinue CO. Notably, the institution reporting a 75% reduction in CO use required a psychiatric consultation to declare necessity prior to the designated nurse specialist initiating CO. Approximately one-third of facilities allow nurses to initiate CO, but only 12% of facilities sanction nurses to discontinue this function. Several other facilities have demonstrated significant decreases of CO use by incorporating a psychiatric nurse liaison to monitor its initiation and use (personal communication; Tomye Modlin, RN, MNSc., and Sharon DiVitto, RNCS).
Patients were placed on CO for a multitude of reasons with some institutional variability. Virtually all rationales for CO resulted from the assessment of a high-risk situation for the patient or others attempting to care for the patient. By far, the two most common reasons for considering CO were risks of self-harm (suicidal ideation or attempt) and confusion. Our findings are consistent with previous studies.1,2,8,10
CO Cost and Reimbursements
CO is frequently an expensive, nonreimbursable hospital expenditure. Managed care has driven down the day rate for medical/surgical beds, partly by requiring hospitals to demonstrate the actual costs for providing care. Hospitals may be able to receive higher diagnosis-related group (DRG) reimbursements for this population in general because they have increased rates of comorbid psychiatric illness,25,26 but these funds are not specified for CO activities. Thus, despite the frequent response in this survey that the funding for CO is included in the hospital rate, it is highly unusual for third-party payers to include this in the day rate, resulting in the hospital paying for this expense out of hospital, departmental, or nursing budgets. Making this assumption, it is likely that three-quarters of CO expenditures are covered in the above hospital-based budgets. Approximately one-quarter of respondents reported that they obtain reimbursement for CO by billing patients directly or by charging the insurance companies. Our discussions with several hospital fiscal personnel suggest that billing patients or payers is not likely to be a fruitful source of reimbursement. In addition, hospitals are paid a flat rate by Medicare based on DRG coding such that it would be viewed as unacceptable to charge families for CO as it is a "medically necessary service." This could also apply to insurance companies that base their payment to hospitals on DRGs. With other insurance policies, hospitals could conceivably bill for a variety of charges (if listed in the contract); however, we were unable to identify a single third-party payer who covered this service as a separate charge.
It was surprising that less than half of the respondents (38.2%) were aware of their institutional expenditures for CO (confirming our second hypothesis), given the potential financial burden involved (see Figure 2). This disappointing response rate could have been because the survey failed to reach the appropriate individual with access to the cost data, or it required too much effort to respond to, or it required information that was too confidential. Nonetheless, most respondents reported that they lacked the tracking systems to monitor the costs and use of CO.
Because of the limited response to specific CO costs, the majority of the following study hypotheses could not be definitively answered: #3) whether the presence of an inpatient psychiatric unit and/or a substance abuse unit significantly decreases the cost of CO in the general hospital; #4) whether the presence of C-L psychiatry services significantly decreases the cost of CO in the general hospital; and #5) whether requiring a C-L psychiatry consultation significantly decreases the overall use and cost of CO.
Potential Role of C-L Psychiatry
In this study, 89% of respondents required a psychiatric consultation for suicidal patients. In contrast only 40% of respondents required a psychiatric consultation for patients requiring CO for other reasons. With the second most frequent indication for CO being confusion (the etiology being neuropsychiatric), the expertise of the C-L psychiatrist in identifying the precipitant(s) and appropriate intervention(s) could be invaluable. Perhaps generalists are adept in this area and the services of psychiatry are not necessary. However, the close involvement of C-L psychiatry has demonstrated significant cost reductions and decreases in use of CO.10
Future Directions for C-L Psychiatry
Possible future directions for C-L psychiatry are as follows: learning from one another and sharing effective and creative strategies for providing for the safety needs of patients (see Table 1); and establishing national guidelines recommending CO standards of care (in order to allow health care administrators to lobby for fair reimbursement based on a mandate to meet established standards of care).
|
ACKNOWLEDGMENTS
|
The authors appreciate the generosity of Mr. Richard Pierson, Vice Chancellor of Clinical Programs, Hospital Director, University Hospital at the University of Arkansas for Medical Sciences (UAMS), who supported the cost of mailing the surveys.
Additional gratitude is extended to the numerous hospital administrators and personnel who responded to this survey, to health care economist Dr. Mingling Zhang who guided the design of survey questions, and to the supportive efforts of Ms. Edwina Benson, Ms. Elizabeth Crone, and Ms. Toni Sullivan.
|
REFERENCES
|
-
Talley S, Davis DS, Goicoechea N, et al: Effect of psychiatric liaison nurse specialist consultation on the care of medical-surgical patients with sitters. Arch Psychiatr Nurs 1990; 4:114–123[CrossRef][Medline]
-
Goldberg RJ: The use of constant observation in general hospitals. Int J Psychiatry Med. 1989; 19;193–201
-
Reich P, Kelly MJ: Suicide attempts by hospitalized medical and surgical patients. N Engl J Med 1976; 194:298–301
-
Shapiro S, Waltzer H: Successful suicides and serious attempts in a general hospital over a 15-year period. Gen Hosp Psychiatry 1980; 2:118–126[CrossRef][Medline]
-
Farberow NL: Suicide prevention in the hospital. Hosp Community Psychiatry 1981; 32:99–104[Abstract/Free Full Text]
-
Goldberg RJ: The assessment of suicide risk in the general hospital. Gen Hosp Psychiatry 1987; 9:446–452[CrossRef][Medline]
-
Travin S, Hyung K, Bluestone H: Prevalence and characteristics of violent patients in a general hospital. NY State J of Med 1990; 12:591–595
-
O'Leary DS: Joint Commission Draft Restraint and Seclusion Standards for Behavioral Health Care Field Evaluation. Joint Commission on Accreditation of Healthcare Organizations. October 19, 1999, p 11
-
Phillips M, Peacock J, Hermanstyne L, et al: Continuous observation — part 1. Who needs it? Can Psychiatr Assoc J 1977; 22:25–28
-
Shugar G, Rehaluk R: Continuous observation for psychiatric inpatients: a critical evaluation. Comprehensive Psychiatry 1990; 30:48–55[CrossRef]
-
Thompson P: The use of seclusion in psychiatric hospitals in the Newcastle area. Br J Psychiatry 1986; 149:471–474[Abstract]
-
Tardiff K: Emergency control measures for psychiatric inpatients. J Nerv Ment Dis 1981; 169:614–618[Medline]
-
Blythe MM: The suicide watch: a re-examination of maximum observation. Perspect Psychiatry Care 1983; 21:90–93
-
Goldberg R: Use of constant observation with potentially suicidal patients in general hospitals. Hosp Community Psychiatry 1987; 38:303–305[Free Full Text]
-
Lamdan RM, Ramchandani D, Schindler BA: Use of constant observation in an urban teaching hospital: implications for improved care. Psychosomatics 1995; 36:189–190
-
Lamdan RM, Ramchandani D, Schindler B: Constant observation in a medical-surgical setting: the role of consultation-liaison psychiatry. Psychosomatics 1996; 37:368–373[Abstract/Free Full Text]
-
O'Dowd MA, Freedman JB, Bernstein G, et al: Reduction in use of constant observation in the general hospital and cost savings as a result of quality improvement monitoring. Psychosomatics 1995; 36:189
-
Lamdan RM, Ramchandani D, O'Dowd MA, et al: A comparison study of constant observation in three urban centers. Psychosomatics 1995; 36:188–189
-
Lanza M: Nurses as patient assault victims: an update, synthesis and recommendations. Arch Psychiatr Nursing 1992; 6:163–171
-
Halleck S: Legal and ethical acts of behavior control,in Biomedical Ethics. New York, McGraw-Hill, 1990, pp 267–273
-
Santulli RB, Oxman TE: The bed enclosure device: an alternative to physical restraints for the agitated older patient. Psychosomatics 1995; 36:190–191
-
Davidson RJ: The American Hospital Guide to the Health Care Field. The American Hospital Association, 1996–1997
-
Peer IN: Suicide litigation and risk management: a review of 32 cases. Bulletin of the American Academy of Psychiatry and Law 1985; 13:209–219
-
Fiesta J: Liability issues: patients with psychiatric problems. Nursing Management 1991; 22:14–17
-
Goldberg RJ, Daly J, Backstrom D: Psychiatric complications and comorbidities in medical inpatients. Gen Hosp Psychiatry 1996; 18:102–105[CrossRef][Medline]
-
Hall RC, Rundell JR, Hirsch TW: Developing a financial viable consultation liaison service. Psychosomatics 1994; 35:308–318[Abstract/Free Full Text]
Get information about faster international access.
Privacy Policy
Copyright © 2000
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
